Terry Lake Assisted Living

A relicensure survey was completed on 10/29/24. Deficiencies were cited. Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy, affecting four current residents.On 10/29/24, the residence' s involuntary discharge grievance policy did not include all of the required elements.On 10/29/24 at 4:10 p.m., the administrator reported that the involuntary discharge grievance policy was developed in January 2024, however, it did not meet all the elements required in Chapter VII, Regulation 10.3 (A-I) and needed to be updated. Based on record review and interview the residence failed to meet the required elements and have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S, affecting four current residents.Findings include:On 10/29/24, the residence' s visitation policy did not include all of the required elements.On 10/29/24 at 4:05 p.m., the administrator reported that the visitation policy was reviewed in March 2024. He reported he thought the policy met regulations, however, it currently did not and needed to be fixed. The administrator reported he expected the policy to meet the required elements of Chapter VII, Regulation 9.2 (A-H). Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting four current residents.Findings include:On 10/29/24, the residence' s 72-hour continuation of care policy and procedure was requested; however, record review revealed the policy failed to provide details on the continuation of care following any emergency.On 10/29/24 at 4:20 p.m., the administrator stated that the 72-hour continuation of care policy and procedure was developed two years ago and reviewed in March 2024. He acknowledged that the policy lacked details to ensure the continuation of care a.. Based on record review and interview, the residence failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records list, controlled substance list, medication error reports and medication disposal records, affecting four current residents.Findings include:On 10/29/24, documentation of the last two quarterly medication administration record audits was requested; however, they were not provided.On 10/29/24 at 12:15 p.m., the administrator reported that the residence was completing the audits; however, they did not document when they were completed or their findings. He acknowledged that the medication audits should be docu.. Based on record review and interviews, the residence failed to ensure its emergency policies addressed or included all required elements, affecting four current residents.Findings include:On 10/29/24, a record review of the residence' s emergency plans and procedures did not include flooding procedures nor addressed all of the required elements.On 10/29/24 at approximately 4:24 p.m., the administrator acknowledged that the residence' s emergency plans and procedures did not include flooding and were missing most of the required elements in Chapter VII, Regulation 10.6 (B-I). He reported the emergency plans and procedures needed to be corrected.

A licensure revisit was completed on 2/2/23 for the previous deficiency cited on 4/12/22. The residence is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

PLEASE NOTE: The emergency rules regarding COVID-19 Vaccination were suspended effective 7/14/22. As such, a revisit could not be conducted for this event to determine compliance with the cited deficiencies.